The Way We Die Now Read Online Free

referred to me for a PEG tube insertion. I saw her at my clinic, where she arrived with a committee of carers, including nurses, a dietician, and a speech and language therapist. The speech and language therapist had carried out a detailed assessment of R.’s swallowing and had diagnosed a ‘severe swallowing disorder’, with a high risk of choking, which in turn could lead to aspiration of food into the lungs, causing pneumonia. She recommended that R. should have a PEG tube. I explained patiently that several studies had shown that PEG tubes, far from curing this problem, actually increase the risk of aspiration pneumonia. The committee expressed its collective displeasure and left the clinic unhappy.
    Some days later, I took a call from R.’s sister. I was expecting trouble, but it turned out that she was a senior nurse and was calling to let me know that she agreed with my assessment. The family, however, were being put under intolerable pressure by the staff at R.’s care home. R. didn’t want a PEG tube herself. Her ability to swallow was indeed poor, but she enjoyed her food and the sociability of mealtimes. Her mother, to whom she had been very close, had died a couple of years before, and R.’s zest for life had diminished gradually since then. In order to mollify the nurses at R.’s care home, I admitted her to the ward for a week or so, and we found that her food intake was just about sufficient for her needs. She went back to the home without a PEG tube. Over the next couple of years, R. had several admissions with chest infection, and one of these infections eventually killed her. I relate this story because in many ways it is so atypical. Peaceful and dignified death is hard to achieve in acute-care hospitals. Some relatives do not thank me for a non-interventionist approach; one family, in a similar clinical scenario, accused me of attempted euthanasia.
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    Although I am primarily a gastroenterologist, I also do a lot of what is known as ‘general’ medicine. General Medicine is a British and Irish phenomenon: the concept is unknown in the US and continental Europe, where sick people generally tend to see a doctor who specializes in what ails them. When I am ‘on take’ for General Medicine, I accept everything that the super-specialists do not want. Most of these patients are frail and old, with multiple diseases. Many have dementia. I am ashamed to admit that I once viewed the care of such patients as unworthy of my attention as a highly specialized gastroenterologist. Many of these people were at the end of their lives and caring for them forced me to think about death and dying.
    The majority of my really sick in-patients are those with liver failure caused by cirrhosis, mainly attributable to alcohol. I witnessed the death, on my first Christmas Day back in Ireland after fourteen years in the UK, of a twenty-seven-year-old boy – for a boy was all he was − with alcoholic liver disease. Since then, I have witnessed many such deaths, as Ireland shot from the bottom to the top of the European alcohol consumption league table. Mortality in these patients is worse than for most cancers, and death from liver failure can be particularly gruesome. The patients tend to be mainly young (in their thirties and forties) and most do not qualify for liver transplantation.
    Some years ago, I was called on a Sunday afternoon by a surgical registrar at the hospital. I was not on-call, but he needed help with a liver cirrhosis patient, who was bleeding profusely from oesophageal varices (varicose veins in the gullet caused by cirrhosis). I drove into the hospital, taking my ten-year-old son with me, because my wife was away at the time. I left my son in my office and went to the operating theatre; I told him I would not be long. The patient, a man in his forties, was in a bad way: he was jaundiced, grotesquely swollen owing to fluid retention, and semi-comatose. We carried out an endoscopy to find (and, we